SCHEDA D’ISCRIZIONE*

Cognome ..................................................................................................…………………………………………….

Nome .......................................................................................................…………………………………………….

Luogo di nascita ......................................................................................……………………………………………...

Data di nascita ..........................................................................................…………………………………………….

Qualifica ...................................................................................................…………………………………………….

Sede di Servizio ........................................................................................…………………………………………….

Incarico attualmente ricoperto ...................................................................……………………………………………..

..................................................................................................................…………………………………………….

Recapito per eventuali comunicazioni ........................................................……………………………………………..

...............................................................tel................................................……………………………………………

Data.............................................. Firma..................................................